Hospital outpatient responses to potential driving impairment due to prescribed medications

Driving and using prescription medicines that have the potential to impair driving is an emerging research area. To date it is characterised by a limited (although growing) number of studies and methodological complexities that make generalisations about impairment due to medications difficult. Consistent evidence has been found for the impairing effects of hypnotics, sedative antidepressants and antihistamines, and narcotic analgesics, although it has been estimated that as many as nine medication classes have the potential to impair driving (Alvarez & del Rio, 2000; Walsh, de Gier, Christopherson, & Verstraete, 2004). There is also evidence for increased negative effects related to concomitant use of other medications and alcohol (Movig et al., 2004; Pringle, Ahern, Heller, Gold, & Brown, 2005). Statistics on the high levels of Australian prescription medication use suggest that consumer awareness of driving impairment due to medicines should be examined. One web-based study has found a low level of awareness, knowledge and risk perceptions among Australian drivers about the impairing effects of various medications on driving (Mallick, Johnston, Goren, & Kennedy, 2007). The lack of awareness and knowledge brings into question the effectiveness of the existing countermeasures. In Australia these consist of the use of ancillary warning labels administered under mandatory regulation and professional guidelines, advice to patients, and the use of Consumer Medicines Information (CMI) with medications that are known to cause impairment. The responsibility for the use of the warnings and related counsel to patients primarily lies with the pharmacist when dispensing relevant medication. A review by the Therapeutic Goods Administration (TGA) noted that in practice, advice to patients may not occur and that CMI is not always available (TGA, 2002). Researchers have also found that patients' recall of verbal counsel is very low (Houts, Bachrach, Witmer, Tringali, Bucher, & Localio, 1998). With healthcare observed as increasingly being provided in outpatient conditions (Davis et al., 2006; Vingilis & MacDonald, 2000), establishing the effectiveness of the warning labels as a countermeasure is especially important. There have been recent international developments in medication categorisation systems and associated medication warning labels. In 2005, France implemented a four-tier medication categorisation and warning system to improve patients' and health professionals' awareness and knowledge of related road safety issues (AFSSAPS, 2005). This warning system uses a pictogram and indicates the level of potential impairment in relation to driving performance through the use of colour and advice on the recommended behaviour to adopt towards driving. The comparable Australian system does not indicate the severity level of potential effects, and does not provide specific guidelines on the attitude or actions that the individual should adopt towards driving. It is reliant upon the patient to be vigilant in self-monitoring effects, to understand the potential ways in which they may be affected and how serious these effects may be, and to adopt the appropriate protective actions. This thesis investigates the responses of a sample of Australian hospital outpatients who receive appropriate labelling and counselling advice about potential driving impairment due to prescribed medicines. It aims to provide baseline data on the understanding and use of relevant medications by a Queensland public hospital outpatient sample recruited through the hospital pharmacy. It includes an exploration and comparison of the effect of the Australian and French medication warning systems on medication user knowledge, attitudes, beliefs and behaviour, and explores whether there are areas in which the Australian system may be improved by including any beneficial elements of the French system. A total of 358 outpatients were surveyed, and a follow-up telephone survey was conducted with a subgroup of consenting participants who were taking at least one medication that required an ancillary warning label about driving impairment. A complementary study of 75 French hospital outpatients was also conducted to further investigate the performance of the warnings. Not surprisingly, medication use among the Australian outpatient sample was high. The ancillary warning labels required to appear on medications that can impair driving were prevalent. A subgroup of participants was identified as being potentially at-risk of driving impaired, based on their reported recent use of medications requiring an ancillary warning label and level of driving activity. The sample reported previous behaviour and held future intentions that were consistent with warning label advice and health protective action. Participants did not express a particular need for being advised by a health professional regarding fitness to drive in relation to their medication. However, it was also apparent from the analysis that the participants would be significantly more likely to follow advice from a doctor than a pharmacist. High levels of knowledge in terms of general principles about effects of alcohol, illicit drugs and combinations of substances, and related health and crash risks were revealed. This may reflect a sample specific effect. Emphasis is placed in the professional guidelines for hospital pharmacists that make it essential that advisory labels are applied to medicines where applicable and that warning advice is given to all patients on medication which may affect driving (SHPA, 2006, p. 221). The research program applied selected theoretical constructs from Schwarzer's (1992) Health Action Process Approach, which has extended constructs from existing health theories such as the Theory of Planned Behavior (Ajzen, 1991) to better account for the intention-behaviour gap often observed when predicting behaviour. This was undertaken to explore the utility of the constructs in understanding and predicting compliance intentions and behaviour with the mandatory medication warning about driving impairment. This investigation revealed that the theoretical constructs related to intention and planning to avoid driving if an effect from the medication was noticed were useful. Not all the theoretical model constructs that had been demonstrated to be significant predictors in previous research on different health behaviours were significant in the present analyses. Positive outcome expectancies from avoiding driving were found to be important influences on forming the intention to avoid driving if an effect due to medication was noticed. In turn, intention was found to be a significant predictor of planning. Other selected theoretical constructs failed to predict compliance with the Australian warning label advice. It is possible that the limited predictive power of a number of constructs including risk perceptions is due to the small sample size obtained at follow up on which the evaluation is based. Alternately, it is possible that the theoretical constructs failed to sufficiently account for issues of particular relevance to the driving situation. The responses of the Australian hospital outpatient sample towards the Australian and French medication warning labels, which differed according to visual characteristics and warning message, were examined. In addition, a complementary study with a sample of French hospital outpatients was undertaken in order to allow general comparisons concerning the performance of the warnings. While a large amount of research exists concerning warning effectiveness, there is little research that has specifically investigated medication warnings relating to driving impairment. General established principles concerning factors that have been demonstrated to enhance warning noticeability and behavioural compliance have been extrapolated and investigated in the present study. The extent to which there is a need for education and improved health messages on this issue was a core issue of investigation in this thesis. Among the Australian sample, the size of the warning label and text, and red colour were the most visually important characteristics. The pictogram used in the French labels was also rated highly, and was salient for a large proportion of the sample. According to the study of French hospital outpatients, the pictogram was perceived to be the most important visual characteristic. Overall, the findings suggest that the Australian approach of using a combination of visual characteristics was important for the majority of the sample but that the use of a pictogram could enhance effects. A high rate of warning recall was found overall and a further important finding was that higher warning label recall was associated with increased number of medication classes taken. These results suggest that increased vigilance and care are associated with the number of medications taken and the associated repetition of the warning message. Significantly higher levels of risk perception were found for the French Level 3 (highest severity) label compared with the comparable mandatory Australian ancillary Label 1 warning. Participants' intentions related to the warning labels indicated that they would be more cautious while taking potentially impairing medication displaying the French Level 3 label compared with the Australian Label 1. These are potentially important findings for the Australian context regarding the current driving impairment warnings about displayed on medication. The findings raise other important implications for the Australian labelling context. An underlying factor may be the differences in the wording of the warning messages that appear on the Australian and French labels. The French label explicitly states "do not drive" while the Australian label states "if affected, do not drive", and the difference in responses may reflect that less severity is perceived where the situation involves the consumer's self-assessment of their impairment. The differences in the assignment of responsibility by the Australian (the consumer assesses and decides) and French (the doctor assesses and decides) approaches for the decision to drive while taking medication raises the core question of who is most able to assess driving impairment due to medication: the consumer, or the health professional? There are pros and cons related to knowledge, expertise and practicalities with either option. However, if the safety of the consumer is the primary aim, then the trend towards stronger risk perceptions and more consistent and cautious behavioural intentions in relation to the French label suggests that this approach may be more beneficial for consumer safety. The observations from the follow-up survey, although based on a small sample size and descriptive in nature, revealed that just over half of the sample recalled seeing a warning label about driving impairment on at least one of their medications. The majority of these respondents reported compliance with the warning advice. However, the results indicated variation in responses concerning alcohol intake and modifying the dose of medication or driving habits so that they could continue to drive, which suggests that the warning advice may not be having the desired impact. The findings of this research have implications for current countermeasures in this area. These have included enhancing the role that prescribing doctors have in providing warnings and advice to patients about the impact that their medication can have on driving, increasing consumer perceptions of the authority of pharmacists on this issue, and the reinforcement of the warning message. More broadly, it is suggested that there would be benefit in a wider dissemination of research-based information on increased crash risk and systematic monitoring and publicity about the representation of medications in crashes resulting in injuries and fatalities. Suggestions for future research concern the continued investigation of the effects of medications and interactions with existing medical conditions and other substances on driving skills, effects of variations in warning label design, individual behaviours and characteristics (particularly among those groups who are dependent upon prescription medication) and validation of consumer self-assessment of impairment.

Validation of a food behavior questionnaire for male blue collar workers

During nutrition intervention programs, some form of dietary assessment is usually necessary. This dietary assessment can be for: initial screening; development of appropriate programs and activities; or, evaluation. Established methods of dietary assessment are not always practical, nor cost effective in such interventions, therefore an abbreviated dietary assessment tool is needed. The Queensland Nutrition Project developed such a tool for male Blue Collar Workers, the Food Behaviour Questionnaire, consisting of 27 food behaviour related questions. This tool has been validated in a sample of 23 men, through full dietary assessment obtained via food frequency questionnaires and 24 hour dietary recalls. Those questions which correlated poorly with the full dietary assessment were deleted from the tool. In all, 13 questions was all that was required to distinguish between high and low dietary intakes of particular nutrients. Three questions when combined had correlations with refined sugar between 0.617 and 0.730 (p<0.005); four questions when combined had correlations with dietary fibre as percentage of energy of 0.45 (p<0.05); five questions when combined had a correlation with total fat of 0.499 (p<0.05); and, 4 questions when combined had a correlation with saturated fat of between 0.451 and 0.589 (p<0.05). A significant correlation could not be found for food behaviour questions with respect to dietary sodium. Correlations for fat as a function of energy could not be found.

A proposed validation framework for expert elicited Bayesian Networks

The popularity of Bayesian Network modelling of complex domains using expert elicitation has raised questions of how one might validate such a model given that no objective dataset exists for the model. Past attempts at delineating a set of tests for establishing confidence in an entirely expert-elicited model have focused on single types of validity stemming from individual sources of uncertainty within the model. This paper seeks to extend the frameworks proposed by earlier researchers by drawing upon other disciplines where measuring latent variables is also an issue. We demonstrate that even in cases where no data exist at all there is a broad range of validity tests that can be used to establish confidence in the validity of a Bayesian Belief Network.

Validation of scales measuring self-efficacy and outcome expectancy in evidence-based practice

Background: Evidence-based practice (EBP) is embraced internationally as an ideal approach to improve patient outcomes and provide cost-effective care. However, despite the support for and apparent benefits of evidence-based practice, it has been shown to be complex and difficult to incorporate into the clinical setting. Research exploring implementation of evidence-based practice has highlighted many internal and external barriers including clinicians’ lack of knowledge and confidence to integrate EBP into their day-to-day work. Nurses in particular often feel ill-equipped with little confidence to find, appraise and implement evidence. Aims: The following study aimed to undertake preliminary testing of the psychometric properties of tools that measure nurses’ self-efficacy and outcome expectancy in regard to evidence-based practice. Methods: A survey design was utilised in which nurses who had either completed an EBP unit or were randomly selected from a major tertiary referral hospital in Brisbane, Australia were sent two newly developed tools: 1) Self-efficacy in Evidence-Based Practice (SE-EBP) scale and 2) Outcome Expectancy for Evidence-Based Practice (OE-EBP) scale. Results: Principal Axis Factoring found three factors with eigenvalues above one for the SE-EBP explaining 73% of the variance and one factor for the OE-EBP scale explaining 82% of the variance. Cronbach’s alpha for SE-EBP, three SE-EBP factors and OE-EBP were all >.91 suggesting some item redundancy. The SE-EBP was able to distinguish between those with no prior exposure to EBP and those who completed an introductory EBP unit. Conclusions: While further investigation of the validity of these tools is needed, preliminary testing indicates that the SE-EBP and OE-EBP scales are valid and reliable instruments for measuring health professionals’ confidence in the process and the outcomes of basing their practice on evidence.

Validation of a new hand-held electronic data capture method for continuous monitoring of subjective appetite sensations

Background When large scale trials are investigating the effects of interventions on appetite, it is paramount to efficiently monitor large amounts of human data. The original hand-held Electronic Appetite Ratings System (EARS) was designed to facilitate the administering and data management of visual analogue scales (VAS) of subjective appetite sensations. The purpose of this study was to validate a novel hand-held method (EARS II (HP® iPAQ)) against the standard Pen and Paper (P&P) method and the previously validated EARS. Methods Twelve participants (5 male, 7 female, aged 18-40) were involved in a fully repeated measures design. Participants were randomly assigned in a crossover design, to either high fat (>48% fat) or low fat (<28% fat) meal days, one week apart and completed ratings using the three data capture methods ordered according to Latin Square. The first set of appetite sensations was completed in a fasted state, immediately before a fixed breakfast. Thereafter, appetite sensations were completed every thirty minutes for 4h. An ad libitum lunch was provided immediately before completing a final set of appetite sensations. Results Repeated measures ANOVAs were conducted for ratings of hunger, fullness and desire to eat. There were no significant differences between P&P compared with either EARS or EARS II (p > 0.05). Correlation coefficients between P&P and EARS II, controlling for age and gender, were performed on Area Under the Curve ratings. R2 for Hunger (0.89), Fullness (0.96) and Desire to Eat (0.95) were statistically significant (p < 0.05). Conclusions EARS II was sensitive to the impact of a meal and recovery of appetite during the postprandial period and is therefore an effective device for monitoring appetite sensations. This study provides evidence and support for further validation of the novel EARS II method for monitoring appetite sensations during large scale studies. The added versatility means that future uses of the system provides the potential to monitor a range of other behavioural and physiological measures often important in clinical and free living trials.

Validation of de-identified record linkage to ascertain hospital admissions in a cohort study

Background Cohort studies can provide valuable evidence of cause and effect relationships but are subject to loss of participants over time, limiting the validity of findings. Computerised record linkage offers a passive and ongoing method of obtaining health outcomes from existing routinely collected data sources. However, the quality of record linkage is reliant upon the availability and accuracy of common identifying variables. We sought to develop and validate a method for linking a cohort study to a state-wide hospital admissions dataset with limited availability of unique identifying variables. Methods A sample of 2000 participants from a cohort study (n = 41 514) was linked to a state-wide hospitalisations dataset in Victoria, Australia using the national health insurance (Medicare) number and demographic data as identifying variables. Availability of the health insurance number was limited in both datasets; therefore linkage was undertaken both with and without use of this number and agreement tested between both algorithms. Sensitivity was calculated for a sub-sample of 101 participants with a hospital admission confirmed by medical record review. Results Of the 2000 study participants, 85% were found to have a record in the hospitalisations dataset when the national health insurance number and sex were used as linkage variables and 92% when demographic details only were used. When agreement between the two methods was tested the disagreement fraction was 9%, mainly due to "false positive" links when demographic details only were used. A final algorithm that used multiple combinations of identifying variables resulted in a match proportion of 87%. Sensitivity of this final linkage was 95%. Conclusions High quality record linkage of cohort data with a hospitalisations dataset that has limited identifiers can be achieved using combinations of a national health insurance number and demographic data as identifying variables.

Preliminary validation of a novel high-resolution melt-based typing method based on the multilocus sequence typing scheme of Streptococcus pyogenes

The major limitation of current typing methods for Streptococcus pyogenes, such as emm sequence typing and T typing, is that these are based on regions subject to considerable selective pressure. Multilocus sequence typing (MLST) is a better indicator of the genetic backbone of a strain but is not widely used due to high costs. The objective of this study was to develop a robust and cost-effective alternative to S. pyogenes MLST. A 10-member single nucleotide polymorphism (SNP) set that provides a Simpson’s Index of Diversity (D) of 0.99 with respect to the S. pyogenes MLST database was derived. A typing format involving high-resolution melting (HRM) analysis of small fragments nucleated by each of the resolution-optimized SNPs was developed. The fragments were 59–119 bp in size and, based on differences in G+C content, were predicted to generate three to six resolvable HRM curves. The combination of curves across each of the 10 fragments can be used to generate a melt type (MelT) for each sequence type (ST). The 525 STs currently in the S. pyogenes MLST database are predicted to resolve into 298 distinct MelTs and the method is calculated to provide a D of 0.996 against the MLST database. The MelTs are concordant with the S. pyogenes population structure. To validate the method we examined clinical isolates of S. pyogenes of 70 STs. Curves were generated as predicted by G+C content discriminating the 70 STs into 65 distinct MelTs.

Measuring literalism and symbolism in advertisements : scale development and validation

A basic element in advertising strategy is the choice of an appeal. Many researchers have studied communication message form and specifically forms of literalism and symbolism, or some variation. The motives for such study are grounded in increasing the effectiveness of commercial communication messages, especially advertising messages. Advertising research studies typically use forms of literalism (e.g. informativeness) or symbolism (e.g. metaphoric, tropes, schemes figures of speech, and rhetorical figures) as independent variables and compare these against one or more of the traditional advertising effectiveness measures as dependent variable(s). The main challenge in assessing the effectiveness of literalism or symbolism in message content is the discreet identification of the construct. However, no standard, empirically-tested measure was located in the literature.

An assessment tool for selection of appropriate daylighting solutions for buildings in tropical and subtropical regions : Validation using radiance simulation

A new decision-making tool that will assist designers in the selection of appropriate daylighting solutions for buildings in tropical locations has been previously proposed by the authors. Through an evaluation matrix that prioritizes the parameters that best respond to the needs of tropical climates (e.g. reducing solar gain and protection from glare) the tool determines the most appropriate devices for specific climate and building inputs. The tool is effective in demonstrating the broad benefits and limitations of the different daylight strategies for buildings in the tropics. However for thorough analysis and calibration of the tool, validation is necessary. This paper presents a first step in the validation process. RADIANCE simulations were conducted to compare simulation performance with the performance predicted by the tool. To this end, an office building case study in subtropical Brisbane, Australia, and five different daylighting devices including openings, light guiding systems and light transport systems were simulated. Illuminance, light uniformity, daylight penetration and glare analysis were assessed for each device. The results indicate the tool can appropriately rank and recommend daylighting strategies based on specific building inputs for tropical and subtropical regions, making it a useful resource for designers.

Development and validation of the consumer disillusionment toward marketing activity scale

This study examines disillusioned consumers. The theory proposes that this is a group learning to lower their expectations of firm integrity and who, to avoid being let down, ignore marketing activity directly from the firm. This kind of exchange orientation develops as a response to consistent failure in perceptions of firm integrity. The research includes six studies, including over 600 adult consumers, to outline the development and validation of a measure of consumer disillusionment toward marketing activity. Completing the process provides a valid and reliable four-item measure. In addition, the study includes the assessment of the nomological validity of the construct. The nomological validation includes using cue utilization theory to predict that disillusioned consumers favor advertising that provides evidence of verifiable integrity. The validation experiment uses print advertising containing high and low verifiable integrity stimuli. Results confirm the theory with disillusioned consumers focusing less on the firm as source of information. Further, these consumers respond more favorably than non-disillusioned consumers to third party endorsers who serve to verify the firm's attempts to show integrity.

The verdine facies off French Guiana

This chapter reviews green grains from the shelf of French Guiana as a regional example of sedimentologic process occurring on the whole stable continental margin from the Amazon to the Orinoco River. Green grains have been observed and analyzed off the Orinoco delta and on the continental shelf of Surinam. These green grains were identified as “chamosite” and “glauconite.” The muddy coast of French Guiana is generally very flat and occupied by wet swamps and mangrove as a result of the equatorial climate. Most green grains on the continental shelf represent the verdine facies. Green grains are ubiquitous on the shelf and top of the slope off French Guiana. Two sedimentological facies exist: glaucony deeper than 150 m and verdine at shallower depths. The verdine facies has mainly developed from mineral debris and especially chloritized biotite. Carbonate bioclasts and faecal pellets are also utilized. The mica flakes were never wholly replaced by authigenic clay and the phenomenon leads to mixed grains where authigenic and substrate remains are recognizable. Carbonate substrates lead to mainly clay pure green grains becasue the initial carbonate has been dissolved. The formation of verdine can be located in a general marine environment at a comparatively warm sea-water temperature and at a depth probably shallower than 60 m.

Open design of high pressure ratio radial-inflow turbine for academic validation

Computational Fluid Dynamics (CFD) simulations are widely used in mechanical engineering. Although achieving a high level of confidence in numerical modelling is of crucial importance in the field of turbomachinery, verification and validation of CFD simulations are very tricky especially for complex flows encountered in radial turbines. Comprehensive studies of radial machines are available in the literature. Unfortunately, none of them include enough detailed geometric data to be properly reproduced and so cannot be considered for academic research and validation purposes. As a consequence, design improvements of such configurations are difficult. Moreover, it seems that well-developed analyses of radial turbines are used in commercial software but are not available in the open literature especially at high pressure ratios. It is the purpose of this paper to provide a fully open set of data to reproduce the exact geometry of the high pressure ratio single stage radial-inflow turbine used in the Sundstrand Power Systems T-100 Multipurpose Small Power Unit. First, preliminary one-dimensional meanline design and analysis are performed using the commercial software RITAL from Concepts-NREC in order to establish a complete reference test case available for turbomachinery code validation. The proposed design of the existing turbine is then carefully and successfully checked against the geometrical and experimental data partially published in the literature. Then, three-dimensional Reynolds-Averaged Navier-Stokes simulations are conducted by means of the Axcent-PushButton CFDR CFD software. The effect of the tip clearance gap is investigated in detail for a wide range of operating conditions. The results confirm that the 3D geometry is correctly reproduced. It also reveals that the turbine is shocked while designed to give a high-subsonic flow and highlight the importance of the diffuser.

Querying a building information model for construction-specific spatial information

The design and construction community has shown increasing interest in adopting building information models (BIMs). The richness of information provided by BIMs has the potential to streamline the design and construction processes by enabling enhanced communication, coordination, automation and analysis. However, there are many challenges in extracting construction-specific information out of BIMs. In most cases, construction practitioners have to manually identify the required information, which is inefficient and prone to error, particularly for complex, large-scale projects. This paper describes the process and methods we have formalized to partially automate the extraction and querying of construction-specific information from a BIM. We describe methods for analyzing a BIM to query for spatial information that is relevant for construction practitioners, and that is typically represented implicitly in a BIM. Our approach integrates ifcXML data and other spatial data to develop a richer model for construction users. We employ custom 2D topological XQuery predicates to answer a variety of spatial queries. The validation results demonstrate that this approach provides a richer representation of construction-specific information compared to existing BIM tools.

Providing query support to leverage BIM for construction

Building information modeling (BIM) is an emerging technology and process that provides rich and intelligent design information models of a facility, enabling enhanced communication, coordination, analysis, and quality control throughout all phases of a building project. Although there are many documented benefits of BIM for construction, identifying essential construction-specific information out of a BIM in an efficient and meaningful way is still a challenging task. This paper presents a framework that combines feature-based modeling and query processing to leverage BIM for construction. The feature-based modeling representation implemented enriches a BIM by representing construction-specific design features relevant to different construction management (CM) functions. The query processing implemented allows for increased flexibility to specify queries and rapidly generate the desired view from a given BIM according to the varied requirements of a specific practitioner or domain. Central to the framework is the formalization of construction domain knowledge in the form of a feature ontology and query specifications. The implementation of our framework enables the automatic extraction and querying of a wide-range of design conditions that are relevant to construction practitioners. The validation studies conducted demonstrate that our approach is significantly more effective than existing solutions. The research described in this paper has the potential to improve the efficiency and effectiveness of decision-making processes in different CM functions.